Medicaid or Medicare Fraud

A settlement has been reached to resolve False Claims Act Allegations against Memorial Hospital who is accused of engaging in improper financial relationships with referring physicians.

 The State of Ohio will receive a $600,383 share of the recovery.

The allegations against Memorial were based upon violations of statutory requirements.  More specifically, financial relationships that Memorial had with two physicians, where there was a joint venture between Memorial and a pain management physician and an arrangement under which an ophthalmologist purchased intraocular lenses and then resold them to Memorial at inflated prices. 

A settlement has been reached in a whistleblower class action lawsuit brought against American Family Care Inc who is accused of knowingly submitting claims to Medicare for outpatient office visits that were billed at a higher rate than was appropriate.

The whistleblower's portion of the settlement recovery has not been determined.

Originally filed by a whistleblower in October of 2010, the government's case alleged American Family Care knowingly selected Evaluation and Management codes for a level of services that exceeded those actually provided in order to artificially increase the amount of reimbursement it received for those visits.

A settlement has been reached in a whistleblower class action lawsuit brought against Hope Cancer Institute and its owner, Dr. Raj Sadasivan.  They are accused of submitting claims to Medicare, Medicaid and the Federal Employee Health Benefits Program for drugs and services that were not provided to beneficiaries.

Filed in March 2012, the government alleges that, between 2007 and 2011, Sadasivan and Hope Cancer Institute submitted claims to federal health benefit programs for the chemotherapy drugs Rituxan, Avastin and Taxotere that were not provided to federal health care beneficiaries. Sadasivan allegedly instructed the employees of Hope Cancer Institute to bill for a predetermined amount of cancer drugs at certain dosage levels, when lower dosages of these drugs were actually provided to beneficiaries. As a result of these instructions, Hope Cancer Institute submitted inflated claims to federal health care programs for drugs that were not actually provided to patients.

A settlement has been reached to resolve False Claims Act allegations brought against Ashland Hospital Corp. d/b/a King’s Daughters Medical Center (KDMC).  KDMC is accused of submitting false claims to the Medicare and Kentucky Medicaid programs for medically unnecessary coronary stents and diagnostic catheterizations and had prohibited financial relationships with physicians referring patients to the hospital, the Justice Department announced today.

The Commonwealth of Kentucky will receive approximately $1,018,380 of the recovery.

The government alleged that, between 2006 and 2011, KDMC billed for numerous unnecessary coronary stents and diagnostic catheterizations performed by KDMC physicians on Medicare and Medicaid patients who did not need them. The government also alleged that the physicians falsified medical records in order to justify these unnecessary procedures, which allegedly generated millions of dollars in Medicare and Kentucky Medicaid reimbursements for KDMC.

The settlement also resolves allegations that KDMC violated the Stark Law by paying certain cardiologists salaries that were unreasonably high and in excess of fair market value. 

A settlement has been reached in a whistleblower class action lawsuit brought against Medtronic Inc who is accused of using various types of payments to induce physicians to implant pacemakers and defibrillators manufactured and sold by Medtronic.

The whistleblower will receive a $1.73 million share of the government's recovery.

The case was filed in January of 2009 and alleges that Medtronic caused false claims to be submitted to Medicare and Medicaid by using multiple types of illegal kickbacks to induce physicians to implant Medtronic pacemakers and defibrillators. Specifically, Medtronic allegedly induced physicians to use its products by: 1) paying implanting physicians to speak at events intended to increase the flow of referral business; 2) developing marketing/business development plans for physicians at no cost; and 3) providing tickets to sporting events. The United States alleged that Medtronic paid the remuneration to persuade the physicians to continue using Medtronic products or to convert their business from a competitor’s products.

A settlement has been reached in a whistleblower class action lawsuit brought against  Omnicare Inc who is accused of offering improper financial incentives to skilled nursing facilities in return for their continued selection of Omnicare to supply drugs to elderly Medicare and Medicaid beneficiaries.

The government's settlement recovery is in the amount of $124,240,000, of which, the originally filing whistleblower will receive $17.24 million. Additionally, $8.24 million of the recovery will go to various states which jointly funded the Medicaid programs impacted by Omnicare’s conduct.

The settlement resolves claims from two cases. The first whistleblower lawsuit was filed in January of 2010 and a second filed in 2011.  The allegations of the government's lawsuit were that Omnicare submitted false claims by entering into below-cost contracts to supply prescription medication and other pharmaceutical drugs to skilled nursing facilities and their resident patients to induce the facilities to select Omnicare as their pharmacy provider. The facilities were participating providers under agreements with Medicare and Medicaid. In addition to the facilities’ own claims for reimbursement from Medicare for short-term rehabilitation treatment rendered to patients, Omnicare submitted additional claims for reimbursement to Medicare and Medicaid for drugs Omnicare supplied.

A settlement has been reached resolving False Claims Act Allegations by Life Care Services LLC (LCS), a manager of skilled nursing facilities based in Des Moines, Iowa, and CoreCare V LLP, doing business as ParkVista, a skilled nursing facility in Fullerton, California. They are accused of submitting false claims to Medicare for unreasonable or unnecessary rehabilitation therapy purportedly provided by RehabCare Group East Inc., a subsidiary of Kindred Healthcare Inc. 

The government alleges that ParkVista submitted and LCS caused both ParkVista and the Massachusetts facility to submit false claims for rehabilitation therapy.  Additionally, the government contends that LCS and ParkVista failed to prevent RehabCare from providing unreasonable or unnecessary therapy to patients in order to increase Medicare reimbursement to the facilities.  Further allegations include that the reported therapy did not reflect the lower amounts of therapy generally provided to patients over the course of their stay. 

Finally, the settlement resolves the claims that LCS and ParkVista failed to prevent other RehabCare practices designed to inflate Medicare reimbursement, including: in lieu of using individualized evaluations to determine the level of care most suitable for each patient’s clinical needs, presumptively placing patients in the highest reimbursement level unless it was shown that the patients could not tolerate that amount of therapy; providing the minimum number of minutes of therapy required to bill at the highest reimbursement level while discouraging the provision of therapy in amounts beyond that minimum threshold, despite the Medicare requirement that the amount of care provided be determined by patients’ clinical needs; arbitrarily shifting the number of minutes of planned therapy between therapy disciplines to ensure targeted reimbursement levels were achieved; and reporting estimated or rounded minutes instead of reporting the actual minutes of therapy provided.

A settlement has been reached in a whistleblower class action lawsuit brought against Episcopal Ministries to the Aging Inc (EMA) who is accused of submitting false claims to Medicare for unreasonable or unnecessary rehabilitation therapy purportedly provided by RehabCare Group East Inc., a subsidiary of Kindred Healthcare Inc. 

The settlement resolves allegations that EMA submitted false claims for rehabilitation therapy at William Hill Manor, a skilled nursing facility EMA owns in Easton, Maryland.  EMA hired RehabCare to provide rehabilitation therapy services to its patients at that facility starting in 2010.  The government alleges that EMA failed to prevent RehabCare from providing unreasonable or unnecessary therapy to patients in order to increase Medicare reimbursement to the facilities.  The government contended that among other things the reported therapy did not reflect the lower amounts of therapy generally provided to patients over the course of their stay. 

The settlement further resolves allegations that EMA failed to prevent other RehabCare practices designed to inflate Medicare reimbursement, including: in lieu of using individualized evaluations to determine the level of care most suitable for each patient’s clinical needs, presumptively placing patients in the highest reimbursement level unless it was shown that the patients could not tolerate that amount of therapy; providing the minimum number of minutes of therapy required to bill at the highest reimbursement level while discouraging the provision of therapy in amounts beyond that minimum threshold, despite the Medicare requirement that the amount of care provided be determined by patients’ clinical needs; arbitrarily shifting the number of minutes of planned therapy between therapy disciplines to ensure targeted reimbursement levels were achieved and reporting estimated or rounded minutes instead of reporting the actual minutes of therapy provided.

A settlement has been reached in a whistleblower class action lawsuit brought against Caremark LLC who is accused of knowingly failing to reimburse Medicaid for prescription drug costs paid on behalf of Medicaid beneficiaries who also were eligible for drug benefits under Caremark-administered private health plans.

The whistleblower's share of the $6 million recovery will be $1.02 million plus interest.

The case was filed in 2011 and the complaint allged that Caremark’s RxCLAIM computer platform allegedly failed to pay the full amount due on certain claims because it improperly deducted certain co-payment or deductible amounts when calculating payments.  The government alleged that Caremark’s actions caused Medicaid to incur prescription drug costs for dual eligibles that should have been paid for by the Caremark-administered private health plans rather than Medicaid.    

A settlement has been reached to resolve False Claims Act Allegations by Rite Aid Corporation who is accused of  inappropriately using gift cards as inducements.

A whistleblower will receive a $508,300 share of the settlement. 

The settlement resolves allegations that Rite Aid offered illegal inducements to Medicare and Medicaid beneficiaries to transfer their prescriptions to Rite Aid pharmacies.  The government alleged that from 2008 to 2010, Rite Aid had knowingly and improperly influenced the decisions of Medicare and Medicaid beneficiaries to transfer their prescriptions to Rite Aid pharmacies by offering them gift cards in exchange for their business.